A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

Stop the transfusion.

Obtain a prescription for a diuretic.

Place the client in high-Fowlers position.

Administer epinephrine to the client.

Administer oxygen to the client

Answer and Explanation

Correct Answer : A,C,E

Stop the transfusion, place the client in high-Fowlers position, and administer oxygen to the client. The rationale for these answers is that these actions are appropriate interventions for a client who is experiencing circulatory overload, which is a potential complication of blood transfusion characterized by fluid overload in the lungs and heart failure. Stopping the transfusion will prevent further fluid accumulation, placing the client in high-Fowlers position will facilitate breathing and reduce venous return, and administering oxygen will improve oxygenation and tissue perfusion.

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Correct Answer is C

Explanation

The rationale for this answer is that reading back the prescription to the provider is a safety measure that helps prevent medication errors and ensures accuracy and clarity of communication. It also allows for confirmation and verification of any unclear or incomplete information.

A. Administer an antiemetic B. Offer pain medication. C. Auscultate bowel sounds. D. Palpate the abdomen.

Correct Answer is D

Explanation

The nurse should first palpate the abdomen to assess for signs of appendicitis, such as rebound tenderness, guarding, or rigidity. Appendicitis is a medical emergency that requires prompt diagnosis and treatment to prevent rupture and peritonitis.

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A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse receives a new prescription over the telephone from a client's provider. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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A nurse is assessing a client who is receiving a blood transfusion. The nurse notes lung crackles, hypoxia, and distended neck veins. Which of the following actions should the nurse take? (Select all that apply.)

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